Introduction

Chronic venous leg ulcerations (CVLUs) are one of the most common lower extremity wounds with a recurrence rate of as high as 70%.¹ Among the wound care community, there is a common understanding that optimal healing requires the management of tissue, infection/inflammation, and moisture balance within the wound bed, along with appropriate compression therapy.

It is also vital for patients with CVLUs to be evaluated by a multidisciplinary team. This evaluation includes a comprehensive vascular evaluation from both a venous and arterial standpoint. While there has been tremendous progress in treating venous insufficiency from a surgical perspective along with advanced wound healing techniques, CVLUs are still a major hurdle to overcome.

A Holistic Approach to Chronic Venous Leg Ulcerations (CVLUs)

Taking a broader view of CVLUs may offer some insight, as many wound care clinicians focus mainly on skin breakdown, we often overlook other significant factors that contribute to healing. Perhaps being truly patient-centered means going beyond the surface of wound measurement and pain level to asking about the patient’s wellbeing in emotional and psychological contexts. Often patients with protracted illness feel isolated and are prone to depression. The stress patients endure coping with a CVLU has a continued negative influence that impairs the immune system which further impedes wound healing.² It may be of benefit for clinicians to "check-in" with patients regularly regarding topics including:

• Social isolation
• Eating habits
• Sleep patterns
• Mobility issues

Addressing the need for support beyond the exam room may improve the overall health of chronic wound patients. There is also a strong correlation between spirituality and physical condition, including decreased anxiety and increased resilience in the face of long-term disease.³ The concept of support groups for CVLUs is an opportunity to offer encouragement and a sense of belonging to those undergoing a shared experience. Through the analysis of a case study, wound care professionals can observe how addressing the emotional aspects of chronic wounds, CVLUs in particular, can improve outcomes.

Case Study Discussion

This case study will follow a 69-year-old Caucasian male with a past medical history of hypertension and chronic venous insufficiency. He has a chronic right venous leg ulceration that was present for 6 months prior to any treatment. This patient is a hospital employee and finally came to the wound clinic due to a foul odor and drainage that was embarrassing for him.

Vein mapping revealed significant venous reflux of the right greater saphenous vein, and he was referred to a vascular specialist. The wound was biopsied, and the results showed stasis dermatitis. The baseline care plan included an antimicrobial foam dressing applied with adequate compression therapy. After the venous reflux was addressed surgically, a synthetic hybrid scale fiber matrix graft was used. Healing progressed, but the patient became increasingly frustrated and irritable. At that point, obtaining emotional and psychological support was discussed. Our recommendation was to access the free employee counseling center where confidentiality is priority. Access to a therapist can be conducted online or in person, and the treatment duration can last as long as necessary.

The patient began utilizing the counseling service on campus and was pleasantly surprised by the experience. He related having a more positive outlook, and his rate of healing markedly improved. The mind-body connection never occurred to him, and he admitted that he could get lost in the shuffle of the hectic clinic visit. Keeping the “whole person” mindset regarding wound healing is the best recipe for success and overall patient wellbeing.

Conclusion

Chronic wound care requires a multifaceted approach. Like any other facet of wound care, managing psychological elements is essential to improve outcomes. As treatment methods for chronic venous leg ulcerations improve and advance, those within the multidisciplinary team must not lose sight of treating the whole patient.

References

1. Franks PJ, Barker J, Collier M, et al. Management of patients with venous leg ulcers: Challenges and current best practice. J Wound Care. 2016;25(Sup6):1-64. https://doi.org/10.12968/jowc.2016.25.sup6.s1
2. Haynes S, Holloway S. Theories of stress and coping and how they relate to individuals with venous leg ulceration. Br J Healthcare Manag. 2019;25(5):187-194. https://doi.org/10.12968/bjhc.2019.25.5.187
3. Salomé GM, Pereira VR, Ferreira LM. Spirituality and subjective wellbeing in patients with lower-limb ulceration. J Wound Care. 2013;22(5):230-236. https://doi.org/10.12968/jowc.2013.22.5.230

About the Author

Christine Miller DPM, PhD is a certified wound specialist by the American Board of Wound Management and a Fellow of the American College of Clinical Wound Specialists. She currently serves as the Co-Director of the Limb Salvage Program at the University of Florida, College of Medicine-Jacksonville.